Cantolisis Lateral como Complemento al Acceso Transconjuntival en Fracturas de Órbita, Reporte de Casos / Lateral Cantholysis as a Complement for Transconjunctival Approach in Orbital Fractures, Cases Report

El acceso transconjuntival asociado a cantotomía lateral ha sido utilizado para permitir una mejor visualización de fracturas del piso de órbita. Esta técnica ha reportado entropión, ectropión y complicaciones en el reposicionamiento tarsal. Para disminuir la morbilidad descrita, hemos complementado este acceso con otra técnica denominada "Cantolisis Lateral" la que ha sido ampliamente utilizada como tratamiento de urgencia para hematoma retrobulbar, con pocos reportes sobre su utilidad en el tratamiento de las fracturas orbitarias. Reportamos los resultados post operatorios de la aplicación de la técnica cantolisis lateral como complemento al acceso transconjuntival en una serie de casos de 16 pacientes. La distopía cantal y la discontinuidad del tarso inferior fueron las complicaciones más frecuentes reportadas. Sin embargo, los pacientes no se percataron de ellas. No se reportaron ectropión ni entropión.

Transconjunctival approach associated with lateral canthotomy has been used to allow a better visualization of orbital floor fractures. This technique has reported entropion, ectropion and complications in tarsal repositioning. To decrease the described morbidity, we have complemented this approach with another technique called "Lateral Cantholysis" which has been widely used as an emergency treatment for retrobulbar hematoma, with few reports about its usefulness in the treatment of orbital fractures. We report the postoperative results of the application of the lateral cantholysis technique as a complement to the transconjunctival approach in a case series of 16 patients. Cantal dystopia and lower tarsal discontinuity were the most frequent complications reported. However, patients were not aware of them. No ectropion or entropion were reported.

Transconjunctival Approach Using Lateral Skin Extension for Reconstruction of Orbit Zygomatic Complex Fractures: Technique Description and a Case Series Analysis.

STUDY DESIGN: A descriptive-observational study of a series case report of patients diagnosed with orbito-zygomatic complex (OZMC) fracture with lateral wall involvement, was conducted. All patients were assessed in the Oral and Maxillofacial Surgery Service at Hospital El Carmen, Maipu, Santiago, Chile. OBJECTIVE: The purpose of this study was to evaluate a single-institution experience with the transconjunctival approach to the orbit, utilizing a lateral skin extension as unique approach to access to fronto-zygomatic suture, infraorbital rim and/or orbital floor. METHOD: The authors identified 41 patients with OZMC fractures who underwent to surgical treatment over a 45 months period. Among this group, 21 patients needed fixation with osteosynthesis of the frontozygomatic suture, and 16 of whom were treated with the approach being studied. The authors assessed scleral exposure, eyelid position changes, ectropion, and entropion as outcome measures, and reported satisfactory outcomes at a minimum of 9 months follow-up. CONCLUSIONS: This study concludes that in our experience, the transconjunctival approach utilizing a lateral skin extension allows a direct, easy, and quick access to the entire infra orbital rim, orbital floor, fronto-zygomatic suture and lateral wall of the orbit, up to spheno-zygomatic suture, with low associated morbidity and complications.

Surgical Approaches for Implanting Xen Gel Stent without Conjunctival Dissection.

The XEN Gel Stent (Allergan Inc., an Abbvie company) is an implant that lowers intraocular pressure by creating a filtration pathway from the anterior chamber to the subconjunctival space, using the same pathway as trabeculectomy. While the primary method for implantation is via ab interno approach, it is also possible to implant the device ab externo. This technique paper details the surgical steps for closed conjunctival implantation of the Gel Stent and provides surgical pearls for enhancing outcomes.

Abordaje transconjuntival en comparación con abordaje subciliar para el tratamiento de fracturas orbitarias / Transconjunctival versus subciliary approach for the treatment of orbital fractures

RESUMEN: Introducción: Los abordajes transconjuntival preseptal y subciliar han sido ampliamente utilizados para el manejo quirúrgico de las fracturas orbitarias. Sin embargo, aún existe incertidumbre sobre las complicaciones asociadas a cada uno de estos abordajes. Métodos: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios. Realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Resultados y conclusiones: Identificamos seis revisiones sistemáticas que en conjunto incluyeron 21 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados. Concluimos que el abordaje transconjuntival preseptal podría disminuir tanto la incidencia de ectropión como de un resultado estético insatisfactorio, pero la certeza de la evidencia es baja. Además, este abordaje probablemente disminuye el riesgo de complicaciones intra y postoperatorias, tales como diplopía, parestesia transitoria, equimosis, exposición escleral, laceración del plato tarsal y laceración palpebral inferior. Por otro lado, el abordaje transconjuntival podría aumentar el riesgo de entropión, pero la certeza de la evidencia también es baja.

ABSTRACT: Introduction: The preseptal transconjunctival and subciliary approach have been widely used for the surgical management of orbital fractures. However, there is still uncertainty about the complications associated with each of these approaches. Methods: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. Results and conclusions: We identified six systematic reviews that included 21 primary studies, four of which correspond to randomized trials. We conclude that the preseptal transconjunctival approach could decrease the incidence of ectropion and an unsatisfactory aesthetic result, but the certainty of the evidence is low. Furthermore, this approach probably decreases the risk of intra and postoperative complications, such as diplopia, transient paresthesia, ecchymosis, scleral show, tarsal plate laceration and lower palpebral laceration. On the other hand, the transconjunctival approach could increase the risk of entropion, but the certainty of the evidence is also low.

Acessos cirúrgicos combinados para tratamento de fraturas em assoalho orbital e lâmina papirácea: relato de caso / Combined surgical accesses for treatment of fractures in the orbital floor and lamina papyracea: case repor

A região orbitária é bastante suscetível a traumas, visto que apresenta uma posição exposta, além de ser composta por ossos frágeis. Quando indicada, é preciso intervenção cirúrgica para preservar a função visual e harmonia facial do paciente. Os acessos transconjuntival e transcaruncular são descritos na literatura como formas seguras, rápidas, funcionais e esteticamente benéficas para a abordagem ao assoalho orbitário e lâmina papirácea. Sobre os materiais biocompatíveis utilizados, a placa de titânio é inabsorvível e permite fixação interna rígida, moldada às curvaturas naturais dos ossos, com baixo risco de infecção. As folhas de polietileno poroso são polímeros inertes e não absorvíveis que facilitam o crescimento de tecido e reduzem as chances de rejeição. Nesse relato de caso, evidencia-se paciente masculino, 28 anos, vítima de traumatismo facial após prática esportiva que apresentou fratura de assoalho e parede medial orbitária direita, com indicação de reconstrução orbitária com acessos transconjuntival e transcaruncular para fixação de placa de titânio em assoalho da órbita direita e de folhas de polietileno poroso em lâmina papirácea à direita, respectivamente (AU)

The orbital region is quite susceptible to trauma, since it has an exposed position, besides being com-posed of fragile bones. When indicated, surgical intervention is required to preserve the patient's visual function and facial harmony. Transconjunctival and transcaruncular accesses are described in the literatu-re as safe, fast, functional and with esthetic benefits for the approach to the orbital floor and papyraceous lamina. Among the biocompatible materials used, the titanium plate does not undergo resorption and allows rigid internal fixation, being shaped to the natural curvatures of the bones, with low risk of infec-tion. Porous polyethylene sheets are inert and nonabsorbable polymers that facilitate tissue growth an reduce the chances of rejection. In this case report, a 28-year-old male patient, a victim of facial trauma after sports practice presented a fracture of the floor and the right orbital medial wall, and orbital recons-truction was indicated with transconjunctival and transcaruncular accesses for fixation of titanium plate in the floor of the right orbit and porous polyethylene sheets in papyracea leaf on the right, respectively (AU)

A new instrument to simplify encircling buckle placement.

PURPOSE: The purpose of this study is to describe a new surgical instrument that simplifies 360° silicone band placement, alone or in combination with pars plana vitrectomy, for the treatment of rhegmatogenous retinal detachment. METHODS: The instrument has a straight shank and a curved component in the form of a partial helix, whose purpose is to encircle the perimeter of the eye globe below the rectus muscles. The distal tip of the helix is inserted through a small conjunctival incision in the superior temporal quadrant, and the shank is rotated 360° on its axis until the tip emerges from the insertion point. One end of the silicone band is sutured to the tip, and the instrument is rotated in the opposite direction until both ends of the band are positioned in the same scleral quadrant. The band is sutured to the sclera and the conjunctival incision is closed. Pars plana vitrectomy can then be performed using transconjunctival microincision techniques through the intact conjunctiva. RESULTS: Our experience using the instrument in more than 100 procedures has shown that the new technique considerably reduces surgical trauma: wide opening of the conjunctiva is obviated, there is little manipulation of the extraocular musculature, and only a few sutures are needed. The duration of the procedure is considerably shorter because of the smaller number of surgical maneuvers. CONCLUSION: We describe a new scleral technique facilitated by this surgical instrument, whose objective is safe and effective placement of an encircling silicone band with minimum trauma and a reduction in operating time.

Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors.

AIM: To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C. MATERIALS AND METHODS: Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated. RESULTS: A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient's IOP at last follow-up visit (R2 = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded. CONCLUSION: Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended. HOW TO CITE THIS ARTICLE: Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.